Page: 1
Transcript
Station:
CANBERRA CONFERENCE
UNIT
Date:
14/04/2011
Program:
PRESS CONFERENCE
Time:
10:30 AM
Compere:
0
Summary ID:
C00043329572
Item:
THE AUSTRALIAN TRANSPORT SAFETY BUREAU'S, MARTIN
DOLAN, HOLDS A PRESS CONFERENCE TO RELEASE THE
FINAL INVESTIGATION REPORT INTO THE 3 APRIL 2010
GROUNDING OF CHINESE BULK CARRIER SHEN NENG 1, OFF
THE COAST OF QUEENSLAND.
INTERVIEWEES: MARTIN DOLAN, AUSTRALIAN TRANSPORT
SAFETY BUREAU'S CHIEF COMMISSIONER
Audience:
Male 16+
N/A
MARTIN DOLAN:
Female 16+
N/A
All people
N/A
Okay, ladies and gentlemen, if we're right to go. I'm
Martin Dolan, the chief commissioner of the
Australian Transport Safety Bureau and I'm here to
talk about the release of our final report into the
grounding of Shen Neng 1 at Douglas Shoal on 3
April 2010.
Before I start, I should make it clear that the role of
the Australian Transport Safety Bureau is to
investigate accidents and occurrences with a view to
seeing what can be improved to prevent these things
happening in future. We're explicitly prevented
from allocating blame in any of these matters.
So the Shen Neng 1 had left Gladstone on 3 April
around 11am with a full load of coal, bound for
China. As well, it had nearly 1000 tonnes of heavy
fuel oil, a large proportion of which was stored in
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tanks at the bottom of the vessel. And the plan was
that the ship would navigate through the Great
Barrier Reef north of Gladstone and then east north
east of a place called North Reef Lighthouse. If you
want to see the course, it's actually set out in page
11 of the investigation report.
The global positioning system of the vessel was set
for that initial course, heading north and then eastnorth-east. At about 1.30pm, the second mate who
was on duty, and the master decided to alter the
ship's planned route slightly. Rather than heading
directly north to head slightly more easterly, but
still within the limits of allowed passages through
that part of the reef.
The process of changing that planned route meant
that the crew - in fact in changing that route, the
crew did not alter the GPS settings, so they were
still set for the original course, which led to some
problems with alarms in due course.
At 3.30pm, the vessel altered to the new planned
course. Shortly thereafter the global positioning
system, the GPS, set off an alarm saying you're off
course, because it was still programmed for the
original course. But the crew was aware of that, and
so they just switched off the alarm.
At 4pm the second mate handed over the watch to
the first mate. They had a discussion about the
changed planned course and what was going on,
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and that the GPS had not been reprogrammed. The
first mate then was alone in the wheelhouse with a
seaman acting as a lookout. This is the first time the
first mate had navigated a vessel through this area
and previously, he'd had an extremely busy time
supervising the loading of the ship in Gladstone and
had had approximately two and a half hours of sleep
in the previous 38 hours. So fatigue was a
significant element of what was going on here.
At about 4pm the ship moved into an area that was
covered by a particular chart, Aus 820, a new chart.
They'd previously been on Aus 819. But on the
chart table on the vessel, the first mate didn't change
to the new chart. So he did not have a chart that
showed him a potential hazard, the reef that the
vessel finally ended up grounding on.
At about four-thirty, the vessel reached the point
where it should have changed course and headed
east-north-east. But at that point, the chief engineer
visited the bridge to check some engine revolution
questions and this distracted the first mate who had
intended to fix the ship's position at that time but
decided to wait until 5pm to do so.
At 5pm he did check the position from the GPS,
plotted it onto the chart, realised the vessel was on
course to and very close to Douglas Shoal.
Attempted to alter course but this was too late to
make a difference. The ship grounded at about 12
knots, caused extensive damage to the hull
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including to the fuel tanks and some fuel was
released into the environment as a result.
So what we have here is essentially a succession of
quite simple and small errors on the part of a tired
crew member leading to the grounding of the
vessel. Our focus has been to find out contributing
factors and therefore what can be done about them.
We identified essentially four key issues. The first
was a lack of a fatigue management system on the
vessel, the Shen Neng 1, to ensure that people
keeping watch were actually in a fit state to do so.
The second was that the ship's safety management
systems did not have any procedures or guidance on
how to use the global positioning system route
planning facility, setting off alarms and so on, and
how to deal with those when plans were changed to
a different course for the vessel.
In the time leading up to the grounding, there was
nothing external to the vessel in terms of the
conditions or how the sea looked that gave any
visual cues about the potential approach to a reef.
So the underwater hazards navigation, including the
shoal, were not visible.
And at the time of the grounding, there was no reef
vessel tracking system in place in the sea area off
Gladstone. It was in operation further north on other
parts of the Great Barrier Reef, but was not in place
in this area. This reef vessel tracking system is the
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capacity to actually see and monitor and send
signals out to vessels if they go off track.
As a result of our investigation, we have issued two
safety recommendations to the management
company of Shen Neng 1 relating to those safety
management system issues, fatigue management
and passage planning. And we've also
acknowledged that there is work in train by the
Australian Maritime Safety Authority to extend the
reef vessel tracking system to include coverage of
the waters off Gladstone.
I want to thank the investigation team for what's
been a comprehensive and thorough job and I'm
very happy to answer any of your questions.
QUESTION:
The safety recommendations you've made to the
crew of the Shen Deng 1, how likely is it that they
will take this onboard?
MARTIN DOLAN:
We're confident that the management company will
take this seriously and will take the necessary steps.
We know that they will end up under scrutiny when
they operate in Australian waters again and they
will have to be able to show evidence that they have
paid attention to these sorts of recommendations.
QUESTION:
But they can't be forced upon them, even if they are
in Australian waters?
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MARTIN DOLAN:
We have no power as an investigating agency to
force anyone to do anything. We can make clear
recommendations. The supervision of navigation of
these sorts of vessels in Australia is by the Maritime
Safety Authority and they do have the capacity to
check the various systems of a vessel and to ensure
there's appropriate compliance with standards.
QUESTION:
You mentioned it briefly, but how was that crew
member distracted when he was going to put in the
GPS changes…?
MARTIN DOLAN:
He wasn't meant to put the GPS changes in, he was
meant to change course earlier, at about four-thirty.
It was closer to 20 to five in fact when the key point
of changing of course was.
So there was a distraction to the point where he
should have been able to chart his position and
therefore see where he was heading and the
potential risk. He was distracted by the chief
engineer arriving on the bridge and wanting to
check something that was reasonable to the
operation of the ship. But a tired person was
therefore distracted from another thing he should
have been doing.
QUESTION:
You mentioned a number of - a combination of
small errors. Is there any one that if it hadn't
happened would have prevented this happening?
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MARTIN DOLAN:
I think it's a classic case where there's a sequence of
things. Any individual one of these things should
have had some sort of other protection to stop it
happening. But it was a sequence of things going
wrong that led to a major failure. Which is quite
often what we find in the course of our
investigations.
QUESTION:
Two and a half hours of sleep in 38 and a half
hours, how do you ensure that crew members would
have improve sleeping patterns on a tight schedule
like that?
MARTIN DOLAN:
I think the reality is that the first mate is always
going to be - have principal responsibility for the
loading and therefore a recognition during loading
that he is going to be getting not very much rest.
And so the scheduling of watch keeping and so on
later on should take account of that sort of risk to
the vessel.
So it's how you look at what's going on that's
causing fatigue and how you manage it, because the
aim is that you don't get a fatigued person keeping
watch on one of these vessels and responsible for its
navigation.
QUESTION:
So despite the investigation, because the
recommendations don't have to be enforced, is it
entirely possible that we could see the exact same
thing happen again?
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MARTIN DOLAN:
We think it's unlikely, because there's a range of
things in here, and the key thing that will make a
difference in terms of an added protection in the
system is the extension of the reef vessel tracking
system to this area. So there'll be actually someone
sitting, watching the courses of various ships and
working out whether they may be going into places
they shouldn't.
QUESTION:
Have you previously recommended that that
tracking system be extended, before this case?
MARTIN DOLAN:
Not that I'm aware of. No. Mr Foley tells me we
haven't previously recommended this.
QUESTION:
So has this been a wake up call to other operators?
MARTIN DOLAN:
[Laughs] Sorry, I'm just thinking fatigue, wake up
call. It should be and what we are saying is that
there should be consistent attention paid by people
operating to the risk of fatigue. Fatigue can lead to a
range of serious safety consequences. You need to
have good systems in place and operating to
manage the potential risk of fatigue.
QUESTION:
Is there other parts along the Great Barrier Reef
where there is a potential for the shipping
companies to take short cuts where the tracking
system should also be…
MARTIN DOLAN:
We're satisfied that the extension of the vessel
tracking system to this area off Gladstone meets the
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sort of risk that's been discovered in this case. I
don't think it's reasonable to describe what
happened as a short cut. The course that the vessel
took - it was changed, but it was within the normal
expectation of routes that you can take to get out of
Gladstone. It's not shortcutting; it was just taking a
different course as the most efficient way of getting
out of Gladstone and through the reef.
QUESTION:
The crew made a number of changes just prior to
the impact of the vessel on Douglas Shoal. If those
changes hadn't have been made, would it have been
a much worse grounding? Would we have seen…
MARTIN DOLAN:
I'm happy to be guided by my colleagues on the
detail, but certainly our assessment is that the
interventions were too late and so there wasn't - it
didn't make much difference. It might have slowed
the vessel slightly, turned it, but it was past the
point of no return; this was going to happen
anyway.
QUESTION:
In other investigations that you've done, do you
have anything to indicate that these issues of fatigue
and navigation could be like systemic problems in
cargo carriers?
MARTIN DOLAN:
We have enough evidence - and this is not just
about cargo carriers, this is across the transport
industry and a whole range of investigations we've
done - fatigue remains a key risk in all transport
sectors and needs to be carefully managed.
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If there are no more questions…
QUESTION:
The reef tracking system, how does that work? Is it
the radar system on land, or is it transponders on the
ship that report their position?
MARTIN DOLAN:
It's a combination. So the position of the ship is
essentially established by equipment on the ship and
shore-based equipment, and there's effectively a
control room.
So if you like, it's a maritime equivalent of air
traffic control, except it's more an advisory than a
controlling system. It's - to say this is where you
appear to be going, to get clarification. So it's an
intervention to give information about a potential
problem.
Okay, well, thank you very much for coming and if
you have any further queries, we'd be happy to deal
with them. Thank you very much.
*
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END
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